Evaluating Global Health Progress in the Millennium Development Goals

When the Millennium Development Goals (MDGs) were adopted in 2000 by 189 member states of the United Nations (UN), they were considered a historic framework for focus and accountability by setting international development objectives, including in global public health. With five years remaining for the timetable to meet the MDGs, however, concern exists whether they will be meet.The UN will hold a high-level plenary meeting of world leaders later this month to review the progress, assess obstacles and gaps, and discuss strategies and actions to help meet the MDGs by the target date of 2015.

MDGs
The MDGs consist of eight major objectives that require the participation of developed and developing nations. They entail time-bound targets for addressing extreme poverty, hunger and disease, gender equality, education, education, and environmental sustainability (1). They also express basic human rights: the rights of everyone to good health, education, and shelter. The eighth goal, to build a global partnership for development, includes commitments in development assistance, debt relief, trade, and access to technologies (1). The MDGs and the specific targets in each goal are outlined below (2, 3).

Goal 1—Eradicate extreme poverty and hunger
• Target 1.A: Halve between 1990 and 2015, the proportion of people whose income is less than $1.25 a day
• Target 1.B: Achieve full and productive employment and decent work for all, including women and young people
• Target 1.C: Halve, between 1990 and 2015, the proportion of people who suffer from hunger.

Goal 2—Achieve universal primary education
• Target 2.A: Ensure that by 2015, children, boys and girls alike, will be able to complete a full course of primary schooling.

Goal 3—Promote gender equality and empower women
• Target 3.A: Eliminate gender disparity in primary and secondary education, preferably by 2005, and at all levels of education, no later than 2015.

Goal 4—Reduce child mortality
• Target 4.A Reduce by two thirds, between 1990 and 2015, the the mortality rate for children under the age of five.

Goal 5—Improve maternal health
• Target 5.A: Reduce by three quarters, between 1990 and 2015, the maternal mortality rate.
• Target 5.B: Achieve by 2015, universal access to reproductive health.

Goal 6—Combat HIV/AIDS, malaria, and other diseases
• Target 6.A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS
• Target 6.B: Achieve by 2010 universal access to treatment for HIV/AIDS for all those who need it
• Target 6.C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases.

Goal 7—Ensure environmental sustainability
• Target 7.A: Integrate the principles of sustainable development into country policies and programs and reverse the loss of environmental resources
• Target 7.B: Reduce biodiversity loss, achieving by 2010, a significant reduction in the rate of loss
• Target 7.C: Halve by 2015 the proportion of people without sustainable access to safe drinking water and basic sanitation
• Target 7.D: Have achieved a significant improvement by 2020 in the lives of a least 100 million slum dwellers.

Goal 8—Develop a global partnership for development
• Target 8.A: Develop further an open, rule-based predictable, nondiscriminatory trading and financial system (including a commitment to good governance, development, and poverty reduction, nationally and internationally)
• Target 8.B: Address the special needs of least-developed countries (including providing tariff- and quota-free access for exports of least-developed countries, enhancing debt relief for heavily indebted poor countries and cancellation of official bilateral debt, and offering more generous official development assessment for countries committed to reducing poverty)
• Target 8.C: Address the special needs of landlocked countries and small-island developing states (through the Program of Action for the Sustainable Development of Small-Island Developing States and the outcome of the 22nd special session of the General Assembly)
• Target 8.D: Deal comprehensively with the debt problems of developing countries through national and international measures to make debt sustainable in the long term
• Target 8.E: In cooperation with pharmaceutical companies, provide access to affordable, essential drugs in developing countries
• Target 8.F: In cooperation with the private sector, make available the benefits of new technologies, especially information and communication technology.

Assessment of MDGs
The UN established 60 official indicators to assess the progress on achieving the goals (2). As world leaders approach the meeting on Sept. 20–21 in New York, there is concern that several of the eight MDGs will not be met as originally planned by 2015. “With five years to go to the target date of 2015, the prospect of failing short of achieving the goals because of a lack of commitment is very real,” according to recent UN report (1). “This would be an unacceptable failure from the moral and the practical standpoint. If we fail, the dangers in the world—instability, violence, epidemic diseases, environmental degradation, runaway population growth—will all be multiplie,” said the report. The purpose of the September meeting is to renew the international commitment to achieving the MDGs by reviewing successes, best practices, lessons learned, obstacles, gaps, challenges, and opportunities, according to a UN briefing on the upcoming MDG Summit.

The MDGs are holistic and interconnected, and the inputs of pharmaceuticals and related healthcare efforts play an important role in achieving the MDGs generally and for realizing specific MDGs (2). A recent assessment by the United Nations Development Program (UNDP) and the UN MDG report outlined the successes and gaps in achieving the MDGs, including MDGs relating to global public health, where development, production, and access to pharmaceuticals and vaccines are crucial issues (3).

MDG 4–Reduce child mortality
The UN MDG report says that although child mortality is declining, it is not failing enough to reach the MDG target of reducing by two-thirds the mortality rate for children under the age of five. Since 1990, the mortality rate of children under the age of five in developing countries has dropped 28%. Globally, the total number of deaths from children under the age of five declined from 12.5 million in 1990 to 8.8 million in 2008. Despite these improvements, many countries still have made little or no progress in reducing child mortality. Among the 67 countries with high child mortality rates (i.e., defined as 40 or more deaths per 1000 live births), only 10 are on track to meet the MDG target on child survival (2).

A key target to improving survival rates is to decrease the incidence of four diseases: pneumonia, diarrhea, malaria, and AIDS, which, combined, accounted for 43% of all deaths in children under the age of five globally in 2008. The UN MDG report emphasized the need to refocus attention on treating pneumonia and diarrhea, including the development and use of new treatments for pneumococcal pneumonia and rotaviral diarrhea (2). 

Immunization against measles is another key factor in child mortality, and the dosing regime is an important factor. In 2008, 81% of children in the developing world were immunized against measles, up from 70% in 2000, but access to measles vaccines varied among different social and economic groups (2). Moreover, the UN MDG report said that a single-dose vaccine strategy is not sufficient to prevent measles outbreaks, pointing to data that showed better outcomes in countries that improved routine immunization coverage and used a two-dose regime. The combination of these two factors led to a 78% decline in measles-related deaths globally between 2000 and 2008, from an estimated 733,000 deaths in 2000 to 164,00 in 2008. The UN MDG report, however, cautions that recent funding gaps in immunization programs may make these gains short-lived. The report says that if supplementary immunization activity is not resumed, approximately 1.7 million measles-related deaths will occur between 2010 and 2013 (2).

MDG 4–Combat HIV/AIDS, malaria, and other diseases
The latest epidemiological data indicate that globally, the spread of HIV appears to have peaked in 1996, when 3.5 million people were newly infected (2). By 2008, that number dropped to 2.7 million. AIDS-related mortality peaked in 2004, with 2.2 million deaths and dropped to 2 million deaths by 2008, although HIV remains the world’s leading infectious killer. On a regional basis, sub-Saharan Africa is the most heavily affected region in the world, accounting for 72% of all new HIV infections in 2008 (2). 

A specific MDG target in the battle against HIV/AIDS was to provide universal access to treatment for HIV/AIDS by 2010. An analysis shows mixed results in achieving this outcome. According to the UN MDG report, a global effort to provide 3 million people in low- and middle-income countries with antiretroviral therapy by 2005 was launched in 2003. At that time, approximately 400,000 people were receiving treatment. By December 2008, that figure had increased 10-fold to approximately 4 million people. The greatest gains were in sub-Saharan Africa, where by the end of 2008, 2.9 million people were receiving treatment (2).

The UN MDG report, however, shows that the rate of new HIV/AID cases outstrips the gains in increasing treatment. For every two individuals who start treatment each year, five people are newly infected. In 2008, 42% of the 8.8 million people needing treatment for HIV in low- and middle- income countries received it, compared with 33% in 2007. Although an improvement, the figures reveal that 5.5 million in need did not have access to treatment (2).

Malaria. Another MDG target is to have halted and begun the reverse of the incidence of malaria and other major diseases by 2015. According to the UN MDG report, half of the world’s population is at risk of becoming infected with malaria. Approximately 243 million cases led to nearly 863,000 deaths in 2008, of which 89% occurred in Africa (2).

The MDG report says that there has been success in achieving sustained malaria control. “Major increases in funding and attention to malaria have accelerated the delivery of critical interventions by reducing bottlenecks in the production, procurement, and delivery of key commodities,” says the report (2). These efforts include increasing the production and delivery of insecticide-treated mosquito nets and increasing access to antimalaria drugs (2).

One strategy to prevent malaria is to increase the dissemination of insecticide-treated mosquito nets. Global production of mosquito nets has increased fivefold since 2004, rising from 30 million nets in 2004 to 150 million nets in 2009. Nearly 200 million nets were delivered to African countries by manufacturers during 2007–2008, but this level fell short of the 350 million nets needed to achieve universal coverage (2).

In terms of malaria treatments, global production of artemisinin-based combination therapies, considered a more effective treatment, has increased from only 500,000 doses in 2001 to 160 million doses in 2009 (2). Access, however, to these treatments varies considerably among African countries and is particularly disparate among children. In only eight of 37 African countries did the proportion of febrile children under five receiving any antimalarial medication reach more than 50%. In African countries, only 10% or less of febrile children were receiving treatment (2).

The UN MDG report shows that external funding for malaria control has increased significantly from less than $10 million in 2003 to $1.5 billion in 2009 (2). This support largely came from a public–private partnership, The Global Fund to Fight Aids, Tuberculosis and Malaria. Despite the increase in funding, total funding for malaria fell short of the estimated $6 billion needed in 2010 for global implementation of malaria-control interventions. Approximately 80% of external funds are targeted for Africa, which accounts for 90% of global cases and deaths relating to malaria (2).

Tuberculosis. The global burden of tuberculosis is gradually declining. Incidence fell from 139 cases per 100,000 people in 2008 after peaking in 2004 at 143 cases per 100,000. The rate of population growth, however, outweighs the reductions in incidence per capita, meaning more people on a global basis are inflicted with tuberculosis. In 2008, approximately 9.4 million new cases of tuberculosis were reported, which was an increase from the 9.3 million cases reported in 2007 (2). On the plus side, however, if current trends are sustained in terms of reducing incidence per capita, the world as a whole will have achieved the MDG target of halting and reversing the incidence of tuberculosis. Although more tuberculosis patients are being cured, the MDG UN report says that halving mortality by 2015 in certain regions such as sub-Sahara Africa is unlikely because of the concomitant problem of HIV/AIDs infection and that sustained funding for tuberculosis-control efforts will be needed regionally and globally to achieve sustained progress.

MDG 8: Develop a global partnership for development
At a meeting of the Gleneagles Group of Eight (G-8) Summit and the UN World Summit in 2005, developed nations agreed to increase their level of aid to the developing world. In 2009, net disbursements of official development assistance (ODA) was $119.6 billion or 0.31% of the combined gross national income (GNI) of developed countries. In real terms, this is a slight increase (0.7%) compared with 2008, although when measured in current US dollars, ODA fell by 2% from $122.3 billion in 2003. If debt relief is excluded, the increase in ODA in real terms in 2008 to 2009 was 6.9%. If humanitarian aid is also excluded, bilateral aid rose by 8.5% in real terms as donor countries increased their core development projects and programs (2).

The global economic downturn, however, has had an effect on future pledges, many of which were made as a percentage of GNI. On the basis of current 2010 budget proposals, as well as lower GNI forecasts, total ODA for 2010 is projected at $108 billion (using 2004 pricing). Only five donor countries have reached or exceeded the UN target for official aid of 0.7% of GNI: Denmark, Luxembourg, The Netherlands, Norway, and Sweden. The largest donor by volume in 2009 was the United States, followed by France, Germany, the United Kingdom, and Japan (2).

Essential medicines.A specific target in the MDG partnership goals is to increase access to affordable essential medicines in developing nations. A recent analysis by the MDG Gap Task Force found that there are large gaps in the availability of essential medicines in the public and private sectors and that prices vary considerably (4). The MDG Task Force was formed in 2007 to track existing international commitments and their fulfillment at the international and country levels in the areas of official development assistance, market access (i.e., trade), debt relief, access to essential medicines, and new technologies. The task force integrates more than 20 UN agencies, including participation from the World Bank and the International Monetary Fund, the Organization for Economic Co-operation and Development, and the World Trade Organization. The United Nations Development Program and the Department of Economic and Social Affairs of the United Nations Secretariat are lead agencies in coordinating the work of the task force (4).

In a 2008 report, the task force concluded that the availability of select essential medicines in developing countries was low (38.1% in the public sector and 63.3% in the private sector), and that access to essential medicines was further hampered following the global economic crisis. Median prices were on average 2.5 times higher than international reference prices in the public sector and 6.1 times higher in the private sector. China, India, Iran, and Uzbekistan were the only countries surveyed in which private-sector patient prices for generic medicines were less than twice the international reference prices (4). In addition to pricing and affordability, other areas of concern were increasing access to medicines for noncommunicable diseases, medicines for children, and medicines for chronic diseases (4).

To address these problems, the MDG Task Force recommended several actions to improve the accessibility and affordability of essential medicines as follows (4):

• Governments should provide additional protection to low-income families to cope with the rising costs of medicines as a consequence of the global economic crisis

• In addition to national efforts, further international efforts should be taken to improve the availability and affordability of essential medicines such as the establishment of international patent pools

• Countries with manufacturing capacity should facilitate the exporting of generic medicines to countries in line with flexibilities contained in the TRIPS (Trade-related Aspects of  Intellectual Property Rights) agreement, and where possible, the exchange of technology between developed and nondeveloped countries for the production of nonessential medicines. Governments of low- and middle- income countries should reform national intellectual property to enable TRIPS flexibilities and facilitate access to medicines for all

• The public sector, in collaboration with the private sector, should strive to made essential medicines available at affordable prices and improve access to healthcare

• Governments, in collaboration with the private sector, should give greater priority to treat chronic disease and improve the accessibility to treat them.

The task force report concluded that increasing access and affordability of essential medicines was crucial for realizing MDG 8 of advancing international partnerships as well as achieving the MDGs on reducing child mortality, improving maternal health, and combating HIV/AIDS, tuberculosis, malaria, and other diseases (4).

References
1. A Forward-Looking Review to Promote An Agreed Action Agenda to Achieve the Millennium Development Goals by 2015: Report of the Secretary General (United Nations, New York, February 2010), www.un.org/ga/search/view_doc.asp?symbol=A/64/665, accessed Aug. 23, 2010.

2.Millennium Development Goals Report 2010 (United Nations, New York, June 2010), http://mdgs.un.org/unsd/mdg/Resources/Static/Products/Progress2010/MDG_Report_2010_En.pdf, accessed Aug. 23, 2010.

3. What Will It Take to Achieve the Millennium Development Goals: An International Assessment (United Nations Development Program, New York, June 2010), http://content.undp.org/go/cms-service/stream/asset/?assetid=2620072, accessed Aug. 23, 2010.

4. Millennium Development Goal 8–Strengthening the Global Partnership for Development in a Time of Crisis: MDG Gap Task Force Report 2008 (United Nations, New York, 2009), www.un.org/esa/policy/mdggap/mdg8report_engw.pdf, accessed Aug. 23, 2010.